An Updated Approach to Suicide Risk Management for Military Patients - Major Depressive Disorder and PTSD: Contemporary Approaches (2025)

Suicide rates among members of the military continue to rise and are higher than rates of the non-military general population. The U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) released updates in 2024 to Clinical Practice Guidelines for the assessment and management of patients at risk for suicide, offering a comprehensive and updated framework for clinicians. In Annals of Internal Medicine, Lisa A. Brenner, PhD, and colleagues provide a summary of the primary recommendations from this work group.¹

Comparison of the 2019 and 2024 guideline frameworks

The 2024 U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) suicide risk guidelines were developed using a stricter application of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system than the 2019 version, leading to recommendations more closely tied to the quality of reviewed evidence. This update narrowed the focus of critical outcomes to suicide deaths and attempts, as opposed to broader suicidal behaviors. A systematic review of 116 studies resulted in some weaker recommendations due to insufficient strong data, prompting calls for further research.

To be clear, the authors stated, “Such changes do not imply that providers should avoid implementation of such interventions, rather that rigorous review of the evidence published within a specified timeframe suggested that there was insufficient data to make stronger recommendations. Some of these downgrades prompted recommendations for future research.”

The 2024 guidelines include 24 recommendations, with the summary provided by Dr. Brenner and coauthors highlighting those most relevant to primary care providers with respect to screening, treatment (both non-pharmacological and pharmacological), and post-acute care. Other recommendations address technology and community-based interventions, which are detailed in the full guideline.

Recommendations for screening

• Risk screening: While suicide risk screening is common practice, the 2024 guidelines found insufficient evidence to definitively recommend, or not recommend, widespread screening programs for reducing suicide. This conclusion stems from limited research, notably an even greater lack of studies measuring actual suicide attempts or deaths as outcomes.

• Screening tools: However, the guidelines do recommend using validated screening tools, including the Columbia Suicide Severity Rating Scale Screener, for identifying at-risk individuals.

• Risk stratification: For comprehensive risk assessments, clinicians should evaluate specific domains such as mental health history, life stressors, and access to lethal means. Although risk stratification is standard practice, there is no conclusive evidence to support the recommendation of any particular stratification tool, so clinicians should rely on clinical interviews to determine risk levels.

Recommendations for nonpharmacologic interventions

• Cognitive behavioral therapy (CBT): CBT focused on suicide prevention showed the strongest evidence of effectiveness, particularly in reducing suicide attempts, especially for those with recent suicidal behavior, and decreasing suicidal ideation for those with a history of self-directed violence. Evidence was inconclusive regarding CBT's ability to reduce suicide death.

• Crisis response planning: There was insufficient evidence to support or refute the use of crisis response and safety planning, with only 1 low quality study meeting inclusion criteria. Also, not enough studies existed to recommend Collaborative Assessment and Management of Suicidality, Dialectical Behavioral Therapy (DBT), or peer-to-peer programs for reducing suicidal behaviors or ideation.

• DBT limitations: Specifically, DBT showed limited evidence of efficacy, with concerns raised about time commitment, staff availability, and the quality of existing studies.

Recommendations for pharmacologic interventions

• Clozapine: The evidence supports the use of clozapine to reduce suicide attempts in individuals with schizophrenia and suicidal ideation or a history of attempts, and ketamine infusion as an adjunct for short-term reduction of suicidal ideation in those with major depressive disorder.

• Other pharmacologic agents: There was insufficient evidence to conclusively recommend ketamine infusions, esketamine, repetitive transcranial magnetic stimulation, or lithium for reducing suicide risk in individuals with mood disorders.

Recommendations for post-acute care

• Supportive Messages: 2 clinical trials provided sufficient evidence for the Work Group to recommend sending postal mail or text messages at regular intervals to reduce suicide attempts.

Challenges and recommendations for future research

The VA/DoD work group identified several areas that pose challenges in suicide prevention research. They noted the difficulty in getting reliable data on suicide prevention because, while devastating, suicide is relatively rare, even in high-risk groups.

Consequently, traditional research methods such as randomly controlled trials often struggle to produce meaningful results due to the need for very large studies to capture enough suicide deaths. The panel suggests building collaborative research networks and data repositories to overcome the limitations of individual studies. They also recommend incorporating high-quality observational studies, which can offer valuable insights into cause and effect when controlled trials are not feasible.

Future research in preventing suicide should consider the following:

• The underlying causes of suicide, including biological, genetic, and social factors
• Using algorithms and data from wearable devices and smartphones
• The role of families and social support
• The effectiveness of various treatments, including medications, therapy, digital tools, and community-based programs
• Implementing effective suicide prevention interventions through a patient-centered approach
• Adjunctive interventions such as case management and lethal means safety counseling.

While there is a lack of strong evidence from randomly controlled trials to support general screening, the guideline acknowledges the limitations of relying solely on such trials. To aid clinical practice, the 2024 VA/DOD guideline advises primary care doctors on suicide risk screening, assessment, and treatment for high-risk patients by providing three algorithms for identifying, assessing, and managing patients at immediate suicide risk.

Published: April 24, 2025